The insurer sent an investigator about my hospital claim — what should I expect?

Insurers sometimes verify a claim through an investigator who may visit you, your doctor or the hospital and ask about your history and the admission. Cooperate, answer accurately, and keep a note of what you were asked and anything you signed. IRDAI's master circular still requires a non-cashless health claim to be settled within 15 days of submission, with interest at bank rate plus 2% if it is late, and unlike its life-insurance rules it sets no separate period for investigated health claims.

An investigation is not a rejection. It means the insurer wants to check facts before deciding, for example about your medical history, the admission, or the bills. How you handle it affects the record the decision will rest on.

What the insurer can ask of you

Policy wordings can ask you to cooperate. One insurer's wording, for example, requires the insured to keep medical records and allow the insurer or its representatives to inspect them, and to give the information the insurer needs to settle the claim within a reasonable time.^[1]

Consent still matters. In its section on Ayushman Bharat Health Account records, IRDAI's health master circular says the policyholder's express consent must be obtained for sharing medical records in every instance.^[2]

What an investigator may ask about

• Your medical history: Earlier illnesses, doctors you have seen and when, and any long-term medicines.
• The admission: When symptoms began, who advised admission, and what happened during the stay.
• Earlier insurance: Previous policies and any earlier claims.
• The bills: Payments made, and who made them.

How to handle the visit

1. 1

   Ask who they are

   Ask for identification and a letter from the insurer or TPA authorising the visit.

2. 2

   Answer accurately, and do not guess

   If you are unsure of a date, say you will check your records and send it, then do so in writing.

3. 3

   Read before you sign

   If you are asked to sign a statement, read it fully, correct anything that is wrong, and ask for a copy.

4. 4

   Keep your own note

   Write down the date, the investigator's name, what was asked and what you handed over.

5. 5

   Follow up in writing

   Send the insurer a short email summarising the visit and anything you promised to provide.

Timelines while you are investigated

IRDAI's policyholder-protection master circular requires a non-cashless health claim to be settled within 15 days of submission. If it is not, the claimant is entitled to interest at bank rate plus 2% from the date of intimation to the date of payment. The circular's life-insurance table sets a separate, longer period for death claims that need investigation; its health timeline has no such separate period.^{[3, 4]}

Insurers must also ask for all the documents they need in one go, not piece by piece. If the investigation produces a string of new requests, or the claim stalls, raise it in writing; see how long the insurer has to settle.^[5]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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